Management of Axial Load Skull Injury with High Cord Injury and Quadriplegia

Immediate Prehospital Stabilization

Early spinal immobilization is critical to prevent onset or worsening of neurological deficit in any patient with suspected spinal cord injury 1, 2, 3
Apply manual in-line stabilization (MILS) immediately, combined with a rigid cervical collar 1, 2
Remove only the anterior portion of the cervical collar during intubation procedures to limit cervical spine movement while improving glottic exposure 1, 2, 3
The intubation technique should include rapid sequence induction with direct laryngoscopy 1, 2, 3
Use of a gum elastic bougie to increase first-attempt success rate 1, 2, 3
Retention of cervical spine in neutral axis without Sellick maneuver 1, 2
Succinylcholine can be safely used as the rapid-acting muscle relaxant within the first 48 hours after spinal cord injury 4, 5, 6

For high cervical cord injuries, immediate intubation is mandatory, however the details of this are not cited in the provided text.

Implement a comprehensive respiratory bundle that includes abdominal contention belt during periods of spontaneous breathing or raising procedures, active physiotherapy with mechanically-assisted insufflation/exsufflation device to remove bronchial secretions, and aerosol therapy combining beta-2 mimetics and anticholinergics 4, 5, 6, 7
For upper level spinal cord injury (C2-C5), perform early tracheostomy within the first 7 days to accelerate ventilatory weaning and reduce ICU hospitalization times 4, 5, 6, 7, 3
For lower cervical injuries (C6-C7), perform tracheostomy only after one or more tracheal extubation failures 4, 5, 6, 7

Evaluate for other potential causes of quadriplegia including Guillain-Barré syndrome, which requires different management 3

Implement aggressive prevention measures from the acute phase, including early mobilization once the spine is stabilized, visual and tactile checks of all at-risk areas at least once daily, and repositioning every 2-4 hours 3
Intermittent urinary catheterization is recommended as soon as daily diuresis volume is adequate to reduce urological complications 3
Self-intermittent urethral catheterization is the gold standard recommended by national and international neuro-urology societies 3
Remove indwelling catheters as soon as the patient is medically stable to minimize urological risks 3

Implement multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids 3
Oral gabapentinoids are recommended for more than 6 months for neuropathic pain 3
Add tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient for neuropathic pain 3

Early rehabilitation should begin immediately after stabilization to maximize neurological recovery 3
Key components include physical exercise to enhance central nervous system regeneration through neurotrophic factors, stretching techniques for at least 20 minutes per zone, and for incomplete injuries, gravity-assisted ambulation or body weight support with treadmill training 3

Delaying immobilization in suspected spinal cord injury cases can lead to worsening neurological outcomes 3
Using succinylcholine after 48 hours post-injury risks life-threatening hyperkalemia due to denervation hypersensitivity 4, 5, 6
Neglecting early rehabilitation results in preventable complications and poorer functional outcomes 3
Failing to implement pressure ulcer prevention strategies leads to significant morbidity 3